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FFRCT-Guided Care in Patients With Suspected CAD
Study Questions:
What are the 1-year clinical, economic, and quality-of-life (QOL) outcomes of using fractional flow reserve computed tomographic angiography (FFRCT) instead of usual care in patients with stable chest pain?
Methods:
In the PLATFORM study, consecutive patients with stable, new-onset chest pain were managed by either usual testing (n = 287) or CT angiography (CTA) (n = 297) with selective FFRCT (submitted in 201, analyzed in 177); 581 of 584 (99.5%) completed 1-year follow-up. Endpoints were adjudicated major adverse cardiac events (MACE; death, myocardial infarction, unplanned revascularization), total medical costs, and QOL. A 95% confidence interval for the difference in mean per-patient cost between usual care and FFRCT-guided care cohorts was determined using empirical bootstrap resampling with 100,000 replicates.
Results:
Patients averaged 61 years old, with a mean 49% pretest probability of coronary artery disease (CAD). At 1 year, MACE events were infrequent, with two in each arm of the planned invasive group and in the planned noninvasive cohort (usual care strategy). In the planned invasive stratum, mean costs were 33% lower with CTA and selective FFRCT ($8,127 vs. $12,145 usual care, p < 0.0001 ); in the planned noninvasive stratum, mean costs did not differ when using an FFRCT cost weight of zero ($3,049 FFRCT vs. $2,579; p = 0.82), but were higher when using an FFRCT cost weight equal to CTA. QOL scores improved overall at 1 year (p < 0.001), with similar improvements in both groups, apart from the 5-item EuroQOL scale scores in the noninvasive stratum (mean change of 0.12 for FFRCT vs. 0.07 for usual care; p = 0.02).
Conclusions:
The authors concluded that in patients with stable chest pain and planned invasive coronary angiography, care guided by CTA and selective FFRCT was associated with equivalent clinical outcomes and QOL, and lower costs, compared with usual care over 1-year follow-up.
Perspective:
This prospective study of stable, symptomatic patients with suspected CAD reports that an evaluation strategy based on use of CTA selectively augmented by FFRCT was associated with a high rate of cancellation of planned invasive catheterization, a significantly lower rate of invasive angiography showing no obstructive CAD, improved information available to guide revascularization; and equivalent clinical outcomes, QOL, and radiation exposure as compared with a usual invasive care strategy. Furthermore, the FFRCT-guided strategy was associated with significantly lower resource utilization and cost as compared to patients with planned invasive evaluation. These findings appear to suggest that the combination of anatomic and functional data provided by the FFRCT-guided testing strategy may safely reduce use of invasive catheterization and costs of care over 1 year in selected patients undergoing evaluation for suspected CAD. Additional testing in larger randomized settings is indicated to confirm these findings and to better understand the utility of FFRCT-guided care in patients with CAD.
Keywords: Catheterization, Chest Pain, Coronary Angiography, Coronary Artery Disease, Cost-Benefit Analysis, Diagnostic Imaging, Fractional Flow Reserve, Myocardial, Ischemia, Myocardial Infarction, Myocardial Revascularization, Quality of Life, Tomography, X-Ray Computed
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